wa-law.org > bill > 2025-26 > SB 5845 > Original Bill
The legislature finds that timeliness of payment and administrative burden related to obtaining payment from health carriers are contributing factors to the financial vulnerability for health care providers and health care facilities and impact availability of care and delay the determination of cost sharing for patients.
It is the intent of the legislature to increase transparency and accountability for claims payment timeliness by updating payment standards to better reflect claims operations and provide an objective and quantifiable standard.
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Except as provided in (b) of this subsection, for health care services provided to covered persons, a carrier shall pay or deny a claim from a provider or facility as soon as practical, but no later than 30 days after the receipt of a clean claim by the carrier.
For claims that are not clean, within 14 days of receipt of the claim, the carrier shall send a written notice to the provider or facility acknowledging the date of receipt of the claim and one of the following:
That the carrier is denying payment on all or part of the claim and the specific reason for the denial. The denial shall identify the portion of the claim that is denied and the specific reasons for the denial; or
That additional information or documentation is needed to process the claim. This notice must include a request for the specific information or documentation needed to process the claim. The carrier shall make a good faith effort to request all information or documentation needed to process the claim in a single request.
Following receipt of all information or documentation requested by the carrier in a notice issued pursuant to (b)(ii) of this subsection, the carrier shall consider the claim a clean claim and shall pay or deny the claim within 30 days, except as agreed to in writing by the parties on a claim-by-claim basis.
The receipt date of a claim or additional information or documentation is the date a carrier receives either written or electronic notice of the claim or additional information or documentation. A carrier must establish a reasonable method for confirming receipt of claims and additional information or documentation and responding to provider and facility inquiries about claims.
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A carrier shall pay interest on the amount of any claims for which the carrier fails to comply with the timeline and notice requirements of subsection (1) of this section. Interest shall accrue on each such claim until the claim is resolved by payment, denial, or the final outcome of an appeals process.
Interest shall be assessed at the following rates and shall be calculated monthly as simple interest prorated for any portion of a month:
Beginning on day one and through day 60 following a carrier's failure to comply with any notice or claim settlement requirement in subsection (1)(a) or (b) of this section, interest shall be assessed at the rate of one percent per month on the amount of the unresolved claim.
Beginning on day 61 following a carrier's failure to comply with any notice or claim settlement requirement in subsection (1)(a) or (b) of this section and until the claim is resolved, interest shall be assessed at the rate of one and one-half percent per month on the amount of the unresolved claim.
Any interest paid under this subsection shall be the carrier's responsibility and not be applied by the carrier to a covered person's deductible, copayment, coinsurance, or any similar obligation of the covered person.
The carrier shall add the interest payable to the amount of the unpaid claim and may not require or request the provider or facility to submit an additional claim.
For any claim for which the carrier failed to comply with the requirements of subsection (1)(a) or (b) of this section that is unresolved for more than 90 days, the carrier shall be subject to an administrative penalty as determined by the commissioner in rule.
The requirements of this section do not apply to claims about which there is substantial evidence of fraud or misrepresentation by providers, facilities, or covered persons.
Providers, facilities, and carriers are not required to comply with the requirements of this section if the failure to comply is occasioned by any act of God, bankruptcy, act of a governmental authority responding to an act of God or other emergency, or the result of a strike, lockout, or other labor dispute.
Health carriers are responsible for compliance with the provisions of this chapter and are responsible for the compliance of any person or organization acting on behalf of or at the direction of the carrier or acting pursuant to carrier standards or requirements concerning the coverage of, payment for, or provision of health care services. A carrier may not offer as a defense to a violation of any provision of this chapter that the violation arose from the act or omission of a participating provider or facility, network administrator, claims administrator, health care benefit manager, or other person acting on behalf of or at the direction of the carrier, or acting pursuant to carrier standards or requirements under a contract with the carrier rather than from the direct act or omission of the carrier.
Nothing in this section limits any existing authority of the office of the insurance commissioner under this title to oversee and enforce carrier compliance with applicable statutes and rules.
The requirements of this section apply to plans filed or renewed on or after January 1, 2027.
The commissioner may adopt rules to implement this section.
For purposes of this section, "clean claim" means a claim that has no defect or impropriety, including any lack of any required substantiating documentation, or particular circumstances requiring special treatment that prevents timely payments from being made on the claim. A claim does not lose the status of "clean claim" due to issues related to carrier internal processing or systems.
Each health plan that provides medical insurance offered under this chapter, including plans created by insuring entities, plans not subject to the provisions of Title 48 RCW, and plans created under RCW 41.05.140, are subject to the provisions of RCW 48.43.500, 70.02.045, 48.43.505 through 48.43.535, 48.43.537, 48.43.545, 48.43.550, 70.02.110, 70.02.900, 48.43.190, 48.43.083, 48.43.0128, 48.43.780, 48.43.435, 48.43.815, 48.200.020 through 48.200.280, 48.200.300 through 48.200.320, 48.43.440, 48.43.845, 48.43.732, section 2 of this act, and chapter 48.49 RCW.